Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at NOVA MEN'S MEDICAL CENTER OF FT LAUDERDALE LLC from September 09, 2026 to September 11, 202 . The laboratory was surveyed under 42 CFR Part 493 CLIA requirements. Standard deficiency cited was as follows: D2007 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) (b)(1) The samples must be examined or tested with the laboratory's regular patient workload by personnel who routinely perform the testing in the laboratory, using the laboratory's routine methods. This STANDARD is not met as evidenced by: Based on record review and staff interview, the Laboratory failed to have all testing personnel (TP) rotate through the testing of Proficiency Testing (PT) in the Specialty of Chemistry for four out of four PT events reviewed (2nd, 3rd in 2025 and 1st, 2nd in 2026). Findings included: 1- Review of form CMS-209 signed 09/07/2026 by the Laboratory Director (LD) revealed that the laboratory had five Testing Personnel (TP- A, TP-B, TP-C, TP-D, and TP-E) listed. 2- Review of personnel files revealed that TP- A, TP-D, and TP-E were TP in 2025 and 2026. TP-C left the practice on 04/24/2026. 3-Review of the Proficiency Testing (PT) policy signed by the LD 10/30/2024 stated "Follow your normal routine: Test PT samples in the same manner as you would patient samples. In other words, test PT samples with the regular patient workload using a staff member who routinely performs System testing." 4- Review of American Proficiency Institute (API) PT records for Chemistry 2nd, 3rd in 2025, and 1st, 2nd in 2026 revealed that TP-A performed all four events. Review of the PT Records also showed that the laboratory director did not sign and date the "Performance Review and